National Institute for Health and Clinical Excellence (NICE)
More care should be taken when prescribing antibiotics for pneumonia
NICE has issued its first guideline to improve treatment of people with pneumonia and reduce their risk of death.
Pneumonia is a common condition which causes sickness and can end in death if not treated properly. Every year up to 480,000 adults will develop the condition in the UK1.
Pneumonia usually occurs when a person’s lungs become infected. The microscopic sacs in lungs which usually hold air fill with bacteria or viruses, immune cells and fluid. This means the lungs are not able to work properly. Common symptoms include coughing, fever or difficulty breathing.
Many people will go to their GP with the symptoms of a chest infection. The exact cause and severity needs to be known to determine the best way to treat them. Antibiotics will benefit people whose condition is brought on by a bacterial infection. However if it is caused by a viral infection, antibiotics have no effect and can cause harm because of side effects.
The guideline prioritises recommendations to help GPs and hospital doctors follow the principles of antimicrobial stewardship, such as only prescribing antibiotics when necessary and reviewing the continued need for them.
The guideline includes a recommendation for GPs to use a simple blood test, known as the C-reactive protein (CRP) test2, if it is unclear whether a person has pneumonia and to determine if they should be treated with antibiotics. Antibiotics may not always be needed or the GP and patient may agree to wait to see if their condition worsens before prescribing.
Dr Michael Moore, a GP and member of the guideline development group, explains: “Chest infections provide a tricky problem for GPs, most get better on their own and antibiotics don’t help much at all but some patients have more serious infections and pneumonia. So patients with chesty coughs require careful assessment and thoughtful treatment. Without the use of a chest X-ray, pneumonia can be difficult to distinguish from other common respiratory infections. This poses a challenge for GPs working in primary care as chest X-rays are not usually readily available in surgeries or there can be a delay in getting results.
“There is evidence that using a simple blood test, as well as checking signs and symptoms, can help the GP work out what’s happening – so they can help their patient faster. The CRP test can be carried out in the GP surgery and it helps decide whether or not treatment with antibiotics is needed. With growing concern over antibiotic resistance, the CRP test is an important tool that can help GPs reduce antibiotic prescribing whilst still being confident about offering patients the best treatment.”
Pneumonia can progress rapidly. Almost half (42%) of patients who are diagnosed with pneumonia by their GP will go to hospital. About 1 in 10 of those admitted to hospital with pneumonia will end up in intensive care where they have a 30% risk of dying.
The recommendations advise GPs on how to assess the severity of illness and whether people need to be referred to hospital. The guideline calls for hospitals to have procedures in place that allow diagnosis (including X-rays) and treatment of pneumonia to take place within 4 hours of admission.
The guideline also includes recommendations on the type of antibiotics to offer depending on how severe a person’s pneumonia is. Those with low severity pneumonia3 should be offered a shorter 5-day course of a single antibiotic instead of the standard 7-day course.
Professor Mark Baker, NICE’s director of clinical practice, said: “Pneumonia is very common. If it is not treated properly, people spend more time in hospital or in the worst cases, it can kill.
“Assessing severity of illness is really important to find out the most appropriate way to treat each individual patient. Antibiotics should be offered as soon as possible to people who need them. The recommendations in this new guideline set out how to identify those people with severe pneumonia. There will also be people with less severe illness who may not need antibiotics at all or who could have a shorter course.
“Accurate assessment of respiratory infections like pneumonia allows healthcare professionals to prescribe treatments responsibly. This both reduces costs and any potential harm from over-exposure to antibiotics. We need to make sure that clinicians are absolutely clear on the best way to treat people with pneumonia, whether that’s in hospital or in the community and this guideline provides that.”
The guideline also includes useful information which should be explained to patients recovering from pneumonia to help reduce anxiety and also avoid unnecessary repeat appointments. For example, letting them know that symptoms should steadily improve after starting treatment but it may take up to 6 months to feel back to normal.
Professor Mark Woodhead, consultant in respiratory and general medicine, Central Manchester University Hospitals NHS Foundation Trust and chair of the guideline development group, said: “This guideline emphasises the importance of accurate and timely diagnosis of pneumonia and the use of severity assessment to facilitate patient management including place of care and appropriate antibiotic prescribing. Unfortunately the evidence base for management of hospital-acquired pneumonia was too sparse to allow the development of detailed recommendations leading to this being prioritised as one of a number of topics requiring additional research.”
The full guideline is available at /guidance/CG191.
For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.
Notes to Editors
- Between 0.5% and 1.1% of adults have community-acquired pneumonia every year in the UK. This is equivalent to between 220,000 and 484,000 people in England.
- A C-reactive protein (CRP) test is carried out at the GP’s surgery or in a local clinic blood test and measures the amount of a protein called C-reactive protein in your blood. C-reactive protein is a measure of the general levels of inflammation in your body.
- A risk assessment tool, either the CRB65 or CURB65 score based on factors including age and presence of certain symptoms (confusion, raised respiratory rate, low blood pressure), is used to determine whether patients are at low, intermediate, or high risk of death and this alongside clinical judgment is used to determine illness severity.
About the guidance
- The guideline ‘Pneumonia: diagnosis and management of community- and hospital-acquired pneumonia in adults’ is available at /guidance/CG191.
The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.
Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.
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